providing safe and effective nutrition for people with ... · recognizing hunger and what to do...

Providing Safe and Effective Nutrition for People with Dementia

Janet S. McKee, MS, RDN, CSG, LD/NPresident, Nutritious Lifestyles®

Adequate and nutritious meals become a challenge for those

with Dementia

There are many factors that conspire to prevent adequate

intakes of food and fluids

These include…

Being unable to recognize the purpose of eating

Failing to recognize food as edible

Forgetting when food has been consumed

Difficulty using utensils or feeding oneself

Too many food choices

In addition, the normal aging process also contributes to

the challenge

All of the Senses Decline With Age

This can have an impact on appetite and the ability and desire to eat

The Ability to Taste and Smell is Especially Important

Taste buds atrophy, reducing the ability to taste foods

Sense of smell also declines, which further decreases our sense of taste

Functional Status Also Declines in Aging and Dementia

Hand grip strength declines

Leads to decreased ability to feed oneself

Ill-fitting dentures make chewing difficult

Aging muscles, swallowing function, and neurological function lead to decreased ability to swallow and chew (dysphagia)

Medications Given for Dementia Have Nutrition-related Side

Effects

Weight loss

Decreased appetite

Lethargy at meal times

Memories and Memory Loss in Dementia Also Play a Role in Meal

Intakes

Short-term memory is impaired

Long-term memory may be all that is left

Those with Dementia may remember the foods they ate as children and those served at special occasions

The family mealtimes as a child may play a much larger role in influencing what they want to eat

Nutritional Risks in Dementia

Weight Loss and Malnutrition

Risk increases with decreased intake

Need to find safe and palatable foods that meet nutritional needs and are acceptable

Increased protein needs because of loss of lean body mass

Adequate calories in a concentrated form

Nutritional Risks in Dementia

Dehydration

Reduced thirst sensation

Forgetting what thirst is and what fluid is for

Swallowing difficulties

Need for thickened liquids

Adequate fluid is essential because of increased risk for dehydration

We have to find ways to increase the aroma and the flavor of food,

recreate those lifetime memories,provide adequate food and fluids in a safe manner,

and provide the assistance needed

Making Mealtimes Easier and More Effective

Focus on the priority of EATING!

People with Dementia do not need a restrictive diet (except for texture)

Eating a calorie-dense diet high in protein is most important

Avoid restrictions that make food less tasty

Concentrate on preferred foods

Small frequent high calorie/high protein meals/snacks.

However….

The food does need to be safe for each person

If pureed or chopped diets are needed, they should be honored if tolerated

Thickened liquids should also be provided when needed if accepted


Limit distractions by providing a quiet environment

Avoid noises such as a TV playing, vacuum cleaner running, or loud conversations


Keep the table setting simple Avoid table centerpieces

or plastic fruit

These items can be distracting or dangerous if eaten

Use only the needed utensils

Distinguish the food from the plate Use contrasting colors –

a white plate with a colored tablecloth or placemat

Avoid busy patterns that can be distracting

Terra cotta plates and dishes stimulate appetite and promote

increased intakes. Blues and greens do not!


Check temperatures carefully

People with Dementia may not know if something is too hot

Serve only one food at a time

Too many foods may be overwhelming and confusing


Honor food preferences

Provide food preferences based on observation

New food preferences may develop suddenly

Foods liked in the past may be rejected


Allow plenty of time to eat

Swallowing or chewing difficulties may cause slow eating

Distractions or forgetfulness may also delay eating

An hour or more may be required to finish a meal

If Difficulty Eating:- Assistance

- Cueing

- ST/OT/RDN referral


Make meals a social event if confusion is not too great

Plan meals around favorite special occasions

Preferred table mates


Remember that a person with Dementia may not remember when or what they last ate

If they ask for breakfast repeatedly, serve them breakfast foods

Provide snacks throughout the day

Encourage Independence

Provide adapted serving dishes and utensils

Plates with rims or protective edges

Spoons with larger handles

Finger eating

Encourage Independence

Serve Finger Foods

Chicken nuggets

Fish sticks

Easy to chew sandwiches cut into quarters

Fruit segments

French fries or potato wedges

Veggie sticks (as tolerated)

Minimize Eating Problems

Prepare foods in a form that is easy to chew and swallow Grind foods if needed and accepted

Cut into bite-size pieces

Serve soft foods such as applesauce, cottage cheese, and scrambled eggs

Watch for signs of choking Sit person up straight with head slightly forward

Check mouth at the end of meal for retained food

Aging Nose SyndromeTaste, Appetites, and Declines

Improving Poor Appetite and Intakes

It is important to improve both the taste of food and the nutritional content

Serving tasty food that is also high in calories and protein can help prevent malnutrition and weight loss

Improving the Taste of Foods

You can improve the taste of many foods by adding flavor enhancers, such as butter, sugar, honey, sauces, and gravies

In many cases, enhancers can make foods easier to eat and add additional protein and calories

Increasing the Nutritional Content of Foods

A person with Dementia needs to get the most “bang for the bite”

Every bite they take needs to be nutrient-rich

Large portions of food at each meal can be overwhelming and prevent them from eating

Fortifying Foods Makes Each Bite Nutrient-Rich

Anything with extra calories or protein that tastes good can serve as a fortified food

Sweets – honey, maple syrup, sugar

Fats – butter, sour cream, heavy cream, eggs, cottage cheese

Protein – meats, cheeses, whole milk, powdered milk, yogurt

Many of these are also flavor enhancers

Fortified Foods

Ice cream, milkshakes, puddings

Gravies and sauces over foods

Soups, potatoes and oatmeal fortified with powdered milk, brown sugar, butter

Fortified OatmealIngredients:3 1⁄3 cups oatmeal5 cups half-and-half2 1⁄2 cups water1 1⁄4 tsp salt3 1⁄3 T margarine10 T brown sugar

Directions:Measure half-and-half, water, salt, and margarine into saucepan and bring to a boil. Add oatmeal and cook until thick. Serve with brown sugar on top. Hold at 135˚F or higher until service.

Cool any leftovers to less than 41˚F within 4 hours for storage. Reheat leftovers to 165˚F for a minimum of 15 seconds prior to serving (hold at 135˚F or higher for service).

Nutrient Analysis: 1/2 cup portion = 331 calories, 6.6 g protein, 38 g carbohydrate, 18 g total fat, 44 mg cholesterol, 397 mg sodium, 3 g dietary fiber

Serves 10

Note: Oatmeal must be puréed for level 1 puréed diets.

When providing nutrient-dense foods, texture needs must be considered.

Some restrictions will likely be required for many people with

Dementia.

“Food First” is always the preferred approach.

But when foods don’t work, supplements should be considered.

Supplements…When Food Does Not Work

When a person with Dementia is not eating, be sure that any underlying issues are identified before adding supplements

Supplements can hide underlying problems, such as difficulty with swallowing or feeding difficulties

Supplements…When Food Does Not Work

Supplements should be served between meals to avoid interfering with food intake

Serve supplements at times when the person is most alert and likely to take them

Hydration is also critical in people with Dementia

Hydration Tips

Encourage fluid intake throughout the day

Add flavor enhancers, like Crystal Light or fresh citrus fruit, to water

Serve a variety of beverages to avoid flavor fatigue

Remember to honor thickened liquid needs if accepted

QUESTIONS???

Nutrition, Dementia, and Living Alone

Outline: What can go wrong? Cognitive skills that

impact nutrition. Meals on Wheels pitfalls. Individual choice or red

flag? What strategies can

help?

1

SMAA area: Population 65+: 86,713

(Maine: 1,319,192; oldest state by median age, mostly rural)

30.8 percent of people with memory problems live alone (Data from the 2015 Behavioral Risk Surveillance System, Centers for Disease Control And Prevention)

Southern Maine Agency on Aging

2

SMAA ADI InterventionsTarget: People living alone with dementia without adequate support

Expanded MOW assessment – Pilot in two areas– Case finding: Memory impairment needing support Others needing additional services

– YTD: 443 expanded assessments, 26.5% referred for additional services

Community (Dementia) Support Program

– 35 referrals YTD (3/4 internal)– Case mix: 75% “complex”– Complex care management and

community MDT care planning

ACL Grant # 90AL0001-01-003

Housing needs Death of spouse Isolation and

loneliness Food shopping,

prep, & consumption

Family caregiver issues

Comorbid conditions and health problems

Medication adherence

Driving safety Bill paying Filling out

applications Home safety Falls risks Keeping

appointments Transportation Pet care Avoiding scams Decision

making

Commonly Identified Client Issues

Dementia complicates every issue!

4

Confusion

Thinking orCognition

Memory

Language

Abstraction

Perception

Reasoning

AttentionJudgement

Organization

Confusion

The world we understand

The world we understand

Elements of Thought

Hepburn, K. (2002). The Savvy Caregiver Program. Emory University School of Nursing.

5

What Can Go Wrong With Nutrition?

Memory– Remembering the referral– Remembering the driver and

answering the door– Remembering to eat

Abstraction– Recognizing hunger and what

to do about it– Visualizing and finding food that

is out of sight Perception

– Temperature of food– Recognizing spoiled food– Cellophane on food

Language– Understanding instructions

Organization– Understanding and sequencing

steps to heat meal Attention

– Heating meal and getting distracted

Judgment– Food safety– Safe use of microwave

6

Is This Food?

7

What Edges?

8

How Does This Thing Work?

9

An Overheated Day-Old Meal: Still Okay to Eat?

10

Eccentric Choices or Cognitive Red Flags?

11

“I Just Don’t Like the Meals.”

12

Summary of Red Flags

Forgetting meal is coming Repeated calls asking for help getting food or for information

previously given Not being able to find food that is out of sight Empty refrigerator and cupboards Hoarding food Neglected pets Uneaten food in microwave or on counters Spoiled food; person doesn’t seem to notice Garbage in odd places or piling up Poor grooming; inappropriate clothing Small repairs not being noticed or addressed Denying lack of food or ability to warm up food “I just don’t like the food.”

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Strategies That Can Help Improve Nutrition

Identify people with memory concerns

Assess ability to prepare and eat the meal

Pay attention to other cognitive red flags

Train staff and volunteers to be dementia-capable “eyes on”

Provide warm handoffs Offer one-on-one support

– Warming Crew/friendly visitor– Phone Pals

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More Information

Liz Weaver, MS, LSWAlzheimer’s Disease Grant Manager

Southern Maine Agency on Aging136 U. S. Route One

Scarborough, Maine 04074207-396-6578

[email protected]

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